Modern medicine and indigenous health beliefs: malaria control alongside "Sadsana-phee" (animist belief system) in Lao PDR.

The major religion in Lao PDR is Buddhism, but many ethnic groups in rural Lao PDR hold an animist belief system called "Sadsana-pee". At the same time, the Bourapar District study site in Khammouane Province, Lao PDR is at high risk of malaria infection. Due to their belief in traditional ways of healing, the promotion of malaria prevention and treatment with modern medicine was not always welcomed by the villagers. Based on the results of questionnaire interviews with 240 heads of households from February to March of 2003, the effect of local beliefs on malaria control activities was discussed. Despite widely available western medicine and widely conducted health education, some people still believe that evil spirits cause malaria and rely on traditional medicine and/or religious ceremonies for treatment. Based on our findings, we recommend that future education and malaria control programs be revised and made sensitive to those people holding indigenous beliefs.

Pyrimethamine-sulfadoxine treatment of uncomplicated Plasmodium falciparum malaria in Lao PDR.

A 28-day in vivo treatment trial to evaluate the efficacy of pyrimethamine/sulfadoxine (Fansidar, PS) was conducted in 21 Lao patients with uncomplicated Plasmodium falciparum malaria. Sixteen patients (76%) were completely cured with PS without any reappearance of asexual stage parasitemia during the follow-up examination. On the other hand, 5 patients (24%) failed to respond to this trial medication, resulting in recrudescence of asexual stage P. falciparum malaria. PS resistance resulted in higher prevalence of post-treatment gametocytemia, 25% gametocyte carriers among PS sensitive cases versus 75% of the resistant cases. These findings suggest that although the level of PS resistance is still valid for treatment of malaria in the study area of Lao PDR, post-treatment induction of gametocytemia among resistant cases may result an increase in transmission rate of PS resistant falciparum malaria.

A molecular epidemiologic study of point mutations for pyrimethamine-sulfadoxine resistance of Plasmodium falciparum isolates from Lao PDR.

To understand the current condition of pyrimethamine-sulfadoxine (PS) resistant falciparum malaria in Lao PDR, the frequency of point mutations in dihydrofolate reductase (DHFR) and dihydropteroate synthase (DHPS) genes of Plasmodium falciparum were examined in 50 blood samples collected from the patients with P. falciparum infection in Southern Lao PDR. Point mutations in 5 codons of the DHFR gene, which is known to be related to pyrimethamine resistance, were detected in 15 out of the 50 samples (30%). Among the 15 samples, 10 samples showed a double mutation of codons 59 and 108 (Cys59Arg with Ser108Asn). In the remaining 5 samples, an additional mutation was observed in codon 51 (Asn51 lle), providing a triple mutation of codons 51, 59 and 108. On the other hand, point mutations in the 4 codons of DHPS gene related to sulfadoxine resistance were observed only in 2 samples (4.0%), namely in codon 437 (Ala437Gly). Only one sample showed mutations in both DHFR and DHPS genes. From the results, it should be considered that the frequency of PS resistant malaria is still low in Lao PDR. Continuous monitoring for the PS resistant malaria, however, is necessary because of the increasing use of PS in this country.

Mekong malaria. II. Update of malaria, multi-drug resistance and economic development in the Mekong region of Southeast Asia.

In an expansion of the first Mekong Malaria monograph published in 1999, this second monograph updates the malaria database in the countries comprising the Mekong region of Southeast Asia. The update adds another 3 years' information to cover cumulative data from the 6 Mekong countries (Cambodia, China/Yunnan, Lao PDR, Myanmar, Thailand, Viet Nam) for the six-year period 1999-2001. The objective is to generate a more comprehensive regional perspective in what is a global epicenter of drug resistant falciparum malaria, in order to improve malaria control on a regional basis in the context of social and economic change. The further application of geographical information systems (GIS) to the analysis has underscored the overall asymmetry of disease patterns in the region, with increased emphasis on population mobility in disease spread. Of great importance is the continuing expansion of resistance of P. falciparum to antimalarial drugs in common use and the increasing employment of differing drug combinations as a result. The variation in drug policy among the 6 countries still represents a major obstacle to the institution of region-wide restrictions on drug misuse. An important step forward has been the establishment of 36 sentinel sites throughout the 6 countries, with the objective of standardizing the drug monitoring process; while not all sentinel sites are fully operational yet, the initial implementation has already given encouraging results in relation to disease monitoring. Some decreases in malaria mortality have been recorded. The disease patterns delineated by GIS are particularly instructive when focused on inter-country distribution, which is where more local collaborative effort can be made to rationalize resource utilization and policy development. Placing disease data in the context of socio-economic trends within and between countries serves to further identify the needs and the potential for placing emphasis on resource rationalization on a regional basis. Despite the difficulties, the 6-year time frame represented in this monograph gives confidence that the now well established collaboration is becoming a major factor in improving malaria control on a regional basis and hopefully redressing to a substantial degree the key problem of spread of drug resistance regionally and eventually globally.

Field application and evaluation of a rapid immunochromatographic test for detection of Plasmodium falciparum infection among the inhabitants of Lao PDR.

Field application and evaluation of a rapid immunochromatographic test (ICT) for detection of Plasmodium falciparum infection were performed in 13 villages in a southern province of Lao PDR in 1999. More than 2,000 inhabitants, accounting for 61.8% of the total estimated population, were examined. Malaria infection was confirmed in all villages surveyed by ICT and microscopic diagnosis. The positive rates of P. falciparum malaria by microscopy ranged from 9.7% to 59.2% (mean 27.2%), whereas by ICT they were from 11.6% to 64.5% (mean 29.8%). The positive rates by ICT were generally higher in 8 out of 13 villages. However, a significant difference between the positive rates by microscopy and ICT was not observed in all villages. Plasmodium falciparum infection was actually confirmed by microscopy in 84.1% of specimens that tested positive by ICT. The results by ICT were consistent with those of the microscopic diagnosis, the discrepancy of the results was less than 10% (141/2,066). The ICT was falsely-positive in 4.7% and falsely-negative in 2.1% of the test cases. These results showed the efficacy of ICT not only in the diagnosis of the respective cases, but also in the mass-examination in the field.

Entomological surveys of malaria in Khammouane Province, Lao PDR, in 1999 and 2000.

Anopheline mosquitos and their relation to malaria transmission were studied 3 times: in July and August, 1999; in December, 1999; and in August and September, 2000. The studies took place in the malaria endemic villages of Khammouane Province, southeast of Lao PDR. A total of 28 species were collected using human and animal bait. Human bait attracted predominantly Anopheles dirus and An. minimus, which were identified as vectors by the detection of sporozoites by dissection, PCR, and enzyme-linked immunosorbent assays for Plasmodium falciparum and P. vivax. The vectorial capacity of An. dirus was 0.009-0.428, while that of An. minimus was 0.048-0.186. The inoculation rate of An. dirus was 0.052-0.137 (Boualapha; August, 2000). An. nivipes and its sister species, An. philippinensis, were principally zoophilic, although a considerable number of the females were also attracted to human bait in the villages of the paddy field areas. An. philippinensis infected with oocysts of P. vivax was detected in a specimen collected by animal bait. These two species were considered as vectors in Khammouane Province. Four species, An. notanandai, An. sawadwongporni, An. willmori, and An. hodgkini, had not been recored before in Lao PDR. Information is provided on host preference and the nocturnal biting activities of common species and the incidence of malaria in the study areas.

An ecological survey of dengue vector mosquitos in central Lao PDR.

An ecological survey of dengue vector mosquitos was carried out in June 2000 in central Lao PDR. Two areas in Khammouane Province, Nongbok and Thakhek, were selected for the survey. Of the 7 mosquito species identified, Aedes aegypti was dominant in both study areas. The container index for Ae. aegypti in Nongbok was 51.8% and was significantly higher than that of Thakhek (40.2%); moreover, significant differences between the study areas were found with records to containers and to the conditions surrounding the houses. The key containers in Nongbok were water jars, whereas drums or small or discarded containers had the highest occurrence rate of Ae. aegypti in Thakhek. Mesocyclops aspericornis was found in large water jars and cement water tanks; no Aedes larvae were found at these sites. Strategy to control dengue vectors in the study areas was discussed.